Home Health Provider Change Request

Home Health Provider Change Request

**Once the change is made, we CANNOT revert the change back to the original information. Please ensure you are supplying the correct information as this could result in claims payment issues.**

*Providers must notify Carelon of changes such as: Change in physical location address, closure of physical locations, change in name, change in Tax ID and/or National Provider Identifier (NPI). *

*Change of Ownership requires an official notice letter on a company letter head be attached to the request.

*Updated Tax ID requires an updated W9*

*A new legal name and/or remit changes require the validation of current information and an attached W9*

**To add additional locations please complete the Agency Information Form located at this link provided here:

https://app.smartsheet.com/b/form/aa58d243893c4787a77a953738802dd6**

***For Fax and Phone Updates, please submit complete the Provider Fax Confirmation form here: https://app.smartsheet.com/b/form/cd75eea28640495a96a741eb0ff54728***

*All current information must be provided to submit a change. If not supplied, the request will not be processed.*

Reason For Request*

Select

Health Plan (select all that apply)*

Select

Agency Information

*The information we have been provided prior to any changes*

Legal Name (prior to updates)*

NPI (prior to updates)*

Tax ID (prior to updates)*

Physical Address (prior to updates)*

*Please include address, suite numbers, city, state, and zip code.*

Information Updates

Effective Close Date*

Date Change Took Effect:*

*This is the date that you will no longer use the current provider demographics for authorizations, credentialing information, and claims.*

Old NPI*

New NPI*

Old Tax ID*

New Tax ID*

Old Agency Name (Legal Name)*

New Agency Name (Legal Name)*

Old dba Name*

New DBA Name*

Old Physical Address*

New Physical Address*

Do you have new Remit Information?

*If yes, a new W9 is required. You may upload via the file upload field*

Select

Old Remit Name*

New Remit Name*

Old Remit Address*

New Remit Address*

Contact Information

*Please provide us your contact information in case we need to reach to confirm any additional information. Non business email domain will be verified and confirmed prior to any changes.*

Agency Contact Name*

Agency Contact Phone*

Phone

Your Email*

Comments

File Upload

*Upload W9, required for Remit Changes/dba changes and Tax ID Changes. Documentation required for Change of Ownership*

Drag and drop files here or

*I understand that by checking the attest box below confirms that I acknowledge and agree to the above changes.*

Attest*

Send me a copy of my responses

Privacy Notice|Report Abuse